Encoder-Free ECG-Language Models

Abstract: ECG-LLMs (ELMs) extend recent progress in Multimodal LLMs (MLLMs) to automated ECG interpretation. However, most ELMs follow Vision-LLM (VLM) designs and depend on pretrained ECG encoders, adding architectural and training complexity. Inspired by encoder-free VLMs, we introduce ELF, an encoder-free ELM that replaces the ECG encoder with a single projection layer trained jointly with the LLM. Across five datasets, ELF matches or exceeds state-of-the-art ELMs that use far more complex encoders and training pipelines. We also test whether adding architectural biases to ELF improves performance and find that the single linear projection remains competitive. Finally, we show that ELF, and potentially other ELMs, often rely more on benchmark artifacts and language priors than ECG-derived information, highlighting limitations in current evaluation practices and ELM design. All data and code is available at https://github.com/willxxy/ECG-Bench.